Project Director Assurances Form
This form is to be completed on all grant applications, contract proposals, and requests for external
project support.
Proposal #:
Your Name:
Project Title:
Conflict of Interest Statement
I have read and understand the conflict of interest and conflict of commitment policy as stated in the
Faculty and Professional Personnel Handbook. I have indicated the one statement below that reflects
my situation.
I DO NOT have a significant conflict of financial interest or commitment related to this project.
I DO have a significant conflict of financial interest or commitment related to this project. I will
upload the appropriate disclosure form to the documents area.
Intellectual Property
The project is likely to produce copyrightable works suitable for
commercialization or broad public dissemination.
Yes
No
The project is likely to produce patentable subject matter.
Yes
No
The proposal contains proprietary information held by a non-BSU entity.
Yes
No
Compliance
Are human subjects involved? (Please enter protocol number if available)
IRB Protocol #
Approval Date
Yes
No
Are animal subjects involved? (Please enter protocol number if available)
IACUC Protocol #
Approval Date
Yes
No
Does this project involve use of any of the following?
Yes
No
Yes
No
Radioactive Material(s), Radiation Producing Devices(s), Recombinant
DNA, Biohazardous Chemical(s), Class IIIb or IV Lasers, other
certifications of health, safety and/or environmental compliance.
Vendors/Consultants
Does this proposal include consultants or individual vendors that
have been employed by Ball State University within the last 12 months?
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Indirect Cost Recovery
This proposal includes the maximum indirect costs allowable by the
sponsor.
*Note: If the sponsor does not allow indirect costs, please check Yes.
Yes
No
Supplemental Compensation
I am requesting supplemental compensation that is in addition to,
my regular specified salary (this includes Summer Pay).
Yes
No
Construction Issues
This project is likely to require additional office or laboratory space, or
renovation/remodeling of current space.
Yes
No
Yes
No
Export Control
Will the project involve participation, collaboration or access to
information by foreign nationals, defined as: individuals with foreign
citizenship, foreign governments, foreign associations and corporations,
or foreign political parties?
Note: Foreign nationals granted US citizenship, or permanent residence "green card" or granted status as a
"protected individual,” e.g., political refugees and political asylum holders are "EXEMPT" from deemed
export rule.
Will the project involve the shipment of equipment, technology,
software, materials, data, or other information (outside of the US)?
Yes
No
Will the project involve a foreign subcontract or other foreign
contractual agreement?
Yes
No
Project Director(s) Statement
My signature below certifies that
(1) I will be responsible for technical conduct of the work and for submission of project reports;
(2) I will be responsible for compliance with award terms and conditions set by the agency as well as
with University policies.
In accordance with federal requirements, I certify that:
(3) I have read and understand the Ball State University Policy and Procedures for Responding to
Allegations of Research Misconduct;
(4) I understand that all student researchers and/or post-doctoral fellows will be required to undergo
responsible conduct of research training;
(5) I am not delinquent on any federal debt; and
(6) I am not debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded
from any current transactions by a federal department or agency.
By typing my name in the space below, I hereby certify that the above information is complete and
correct to the best of my knowledge.
Certification (type name)
Rev. Jan. 2015
Date
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